AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (54)

•Diagnostic Errors (51)

•Identification Errors (31)

•Discontinuities, Gaps, and Hand-Off Problems (98)

•Fatigue and Sleep Deprivation (8)

•Medication Safety (404)

•Medical Complications (88)

•Nonsurgical Procedural Complications (31)

•Surgical Complications (145)

•Transfusion Complications (5)

•Psychological and Social Complications (40)

Origin/Sponsor

•Africa (1)

•Asia (15)

•Australia and New Zealand (25)

•Central and South America (3)

Resource Types

•Clinical Guideline (2)

•Journal Article (826)

•Legislation/Regulation (12)

•Meeting/Conference (9)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (54)

•Press Release/Announcement (19)

•Special or Theme Issue (29)

•Tools/Toolkit (12)

•Web Resource (18)

•Grant (8)

Error Types

•Epidemiology of Errors and Adverse Events (281)

•Active Errors (220)

•Latent Errors (70)

•Near Miss (27)

Approach to Improving Safety

•Quality Improvement Strategies (253)

•Legal and Policy Approaches (98)

•Error Reporting and Analysis (336)

•Communication Improvement (286)

•Human Factors Engineering (187)

•Teamwork (270)

•Specialization of Care (79)

•Logistical Approaches (47)

•Culture of Safety (144)

•Technologic Approaches (308)

•Education and Training (155)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (896)

•Health Care Executives and Administrators (945)

•Non-Health Care Professionals (525)

•Patients (43)

Setting of Care

•Hospitals (651)

•Psychiatric Facilities (5)

•Residential Facilities (18)

•Ambulatory Care (102)

•Outpatient Surgery (7)

•Patient Transport (10)

1 - 20 of 1061

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STUDY

Using Failure Mode and Effects Analysis for safe administration of chemotherapy to hospitalized children with cancer.

Robinson DL, Heigham M, Clark J. Jt Comm J Qual Patient Saf. 2006;32:161-166.

STUDY

Error reduction in pediatric chemotherapy: computerized order entry and failure modes and effects analysis.

Kim GR, Chen AR, Arceci RJ, et al. Arch Pediatr Adolesc Med. 2006;160:495-498.

STUDY

Multidisciplinary system for detecting medication errors in antineoplastic chemotherapy.

Serrano-Fabiá A, Albert-Marí A, Almenar-Cubells D, Jiménez-Torres NV. J Oncol Pharm Pract. 2010;16:105-112.

STUDY

Computerized physician order entry of injectable antineoplastic drugs: an epidemiologic study of prescribing medication errors.

Nerich V, Limat S, Demarchi M, et al. Int J Med Inform. 2010;79:699-706.

COMMENTARY

Patient safety beyond the hospital.

Gandhi TK, Lee TH. N Engl J Med. 2010;363:1001-1003.

STUDY

Using CPOE to improve communication, safety, and policy compliance when ordering pediatric chemotherapy.

Crossno CL, Cartwright JA, Hargrove FR. Hosp Pharm. 2007;42:368–373.

STUDY

Using an enhanced oral chemotherapy computerized provider order entry system to reduce prescribing errors and improve safety.

Collins CM, Elsaid KA. Int J Qual Health Care. 2011;23:36-43.

STUDY

Failure mode and effects analysis outputs: are they valid?

Shebl NA, Franklin BD, Barber N. BMC Health Serv Res. 2012;12:150.

STUDY

Chemotherapy medication errors in a pediatric cancer treatment center: prospective characterization of error types and frequency and development of a quality improvement initiative to lower the error rate.

Watts RG, Parsons K. Pediatr Blood Cancer. 2013 Mar 20; [Epub ahead of print].

STUDY

Oral outpatient chemotherapy medication errors in children with acute lymphoblastic leukemia.

Taylor JA, Winter L, Geyer LJ, Hawkins DS. Cancer. 2006;107:1400-1406.

STUDY

The impact of drug shortages on children with cancer—the example of mechlorethamine.

Metzger ML, Billett A, Link MP. N Engl J Med. 2012;367:2461-2463.

STUDY

Using Health Care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system.

DeRosier J, Stalhandske E, Bagian JP, Nudell T. Jt Comm J Qual Improv. 2002;28:248-267, 209.

STUDY

Interruptions during the delivery of high-risk medications.

Trbovich P, Prakash V, Stewart J, Trip K, Savage P. J Nurs Adm. 2010;40:211-218.

COMMENTARY

A practical framework for patient care teams to prospectively identify and mitigate clinical hazards.

Herzer KR, Rodriguez-Paz JM, Doyle PA, et al. Jt Comm J Qual Patient Saf. 2009;35:72-81.

STUDY

Failure mode and effects analysis: an empirical comparison of failure mode scoring procedures.

Ashley L, Armitage G. J Patient Saf. 2010;6:210-215.

STUDY

A chemotherapy incident reporting and improvement system.

France DJ, Miles P, Cartwright J, et al. Jt Comm J Qual Saf. 2003;29:171-180.

STUDY

Dealing with unforeseen complexity in the OR: the role of heedful interrelating in medical teams.

Schraagen JM. Theor Issues Ergon Sci. 2011;12:256-272.

STUDY

Utilising improvement science methods to optimise medication reconciliation.

White CM, Schoettker PJ, Conway PH, et al. BMJ Qual Saf. 2011;20:372-380.

STUDY

Using a preprinted order sheet to reduce prescription errors in a pediatric emergency department: a randomized, controlled trial.

Kozer E, Scolnik D, MacPherson A, Rauchwerger D, Koren G. Pediatrics. 2005;116:1299-1302.

STUDY

Effect of computerisation on the quality and safety of chemotherapy prescription.

Voeffray M, Pannatier A, Stupp R, et al. Qual Saf Health Care. 2006;15:418-421.

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